1. Health Disparities/ Diabetes Care Sheldon Greenfield, MD Orange County Diabetes Education Collaborative Conference January 31, 2009

2. Optimizing the ‘Physician Effect’ on HbA1c levels

3. Coached Care Team Quyen Ngo-Metzger, MD, MPH Israel De Alba, MD, MPH Dara Sorkin, PhD John Billimek, PhD Dana Mukamel, PhD Community-based Coaches

4. Background: Disparities in Diabetes Care in the U.S. More ethnic minorities fail to meet diabetes quality benchmarks than non- minority patients Rates of diabetes complications are higher among many ethnic minorities All cause mortality rates are higher among African Americans and Hispanic patients

5. Purposes of Study Document disparities in diabetes care among three ethnic groups (Mexicans, Vietnamese, Non-Hispanic Whites) in defined population Reduce disparities through Coached Care program for improving patients’ participation in care using community- based patients with diabetes

6. Study Designs Diabetes Registry (population definition) Cross-sectional DAWN Minority Survey (measures development; comparison ethnic groups) Randomized controlled trial (intervention test)

7. Sampling Diabetes Registry: –All patients seen for diabetes at UCI Medical Center clinics Cross-sectional DAWN Minority Survey: –Random sample 300 patients each ethnic group Randomized controlled trial: –Balanced design, n=100 exp/cont by ethnic group

9. Optimizing the ‘Physician Effect’ on HbA1c levels

10. Features of Coached Care Algorithm mapping decisions, treatment options; detailed explanations Patient’s medical record; tailored, personalized information Reviewed immediately before office visit ‘Coaching’ for more effective participation during visit

11. Tailored Algorithm Information: Example, Patient on Insulin Using insulin alone Adherence as instructed Problems with insulin regimen yes no OPTIONS Change insulin to rapid acting qd Use insulin Pen for administration Stop or reduce insulin; add oral agent Improve diet, exercises both yes

13. Control Group Matched for session lengthMatched for session length Same venue, same staffSame venue, same staff Content = state of the art patient education materials for each diseaseContent = state of the art patient education materials for each disease

14. PRIOR RESULTS FROM THE COACHED CARE PROGRAM: Health Outcomes Compared to controls, patients in experimental group had:Compared to controls, patients in experimental group had: – 1.5% reduction in HbA1 c – 10 mm Hg reduction in diastolic BP – 25% reduction in symptoms – 30% improvement in functional status

15. PRIOR RESULTS FROM THE COACHED CARE PROGRAM: Communication Compared to controls, patients in experimental group (based on audiotapes):Compared to controls, patients in experimental group (based on audiotapes): – 3 times more queries, ‘controlling’ conversational behaviors – 2 times more effective in information seeking – 30% increase in emotional response from physicians

16. Features of Coached Care for Diabetes Program Use of community-based ethnic minority coaches Training program for, quality monitoring of coaches Use of diabetes registry at UC Irvine to ensure representativeness of patient sampling, assignment

17. Coached Care for Diabetes Program: DAWN Minority Survey Results

18. Characteristics of Patient Sample CharacteristicsRegistry (n=3,894) Survey Sample (n=1001) Mean HbA1c7.6 [1.5]8.3 [1.8] Mean LDL96.1 [28.6]103.2 [33.0]

19. Baseline HbA1c by Ethnicity Ethnic GroupMean HbA1c White7.3 [1.5] Hispanic8.2 [2.0] Vietnamese6.8 [0.9] F-value = 63.1, p<.001

20. % HbA1c <7 by Ethnicity Ethnic Group% HbA1c <7 White54.8 Hispanic32.4 Vietnamese55.6 Chi Square = 49.7, p<.001

21. DAWN Minority Survey Measures General health status Diabetes specific health status Adherence to diabetes regimen Disease management/health enhancing behaviors Quality of interpersonal care Access to care Total Illness Burden

22. DAWN Minority Survey Measures General health status –SF-36 –General health distress –WHO –EuroQual –CESD –Quality of life –Stress level Diabetes specific health status –Diabetes management hassles –Diabetes frustration –Diabetes distress –Diabetes worry/concern –Diabetes burden –Stress managing diabetes

23. Sample Questions: Diabetes Management Hassles “During the past 4 weeks, how much of a problem or hassle has each of the following been for you in your everyday life?” (A major hassle No hassle at all) h. Having to keep your schedule (eating, drugs, exercise) in mind all the time…..

24. Sample Questions: Diabetes Frustrations “Sometimes diabetes can be a source of frustration to those who have it. During the past 4 weeks, how often: (All of the time None of the time) a. Were you frustrated about diabetes?....

25. Sample Questions: Diabetes Worries or Concern “Sometimes people with diabetes have concerns about complications that may develop. How much are you worried or concerned about each of the following?” (Extremely worried Not worried at all) a. Losing my eyesight from diabetes?....

26. Sample Questions: Diabetes Burden “Overall, how much of a burden is your having diabetes on you and your family in each of the following areas?” (Very great burden No burden at all) a.Our finances in general?.... b.Our finances due to the cost of my medications?….

27. Ethnic Differences: Survey Measures Measure: General health Whites (n=216) Hispanic (n=502) Vietnamese (n=283) Mean Diff P-value SF-36 PFI1065.465.157.3<.01 SF-36 Role Physical 67.169.953.9<.01 WHO55.857.154.4.331 EuroQual2.1 2.7.381 CESD10.712.213.9<.01

28. Ethnic Differences: Survey Measures Measure: Diabetes health Whites (n=216) Hispanic (n=502) Vietnamese (n=283) Mean Diff P-value Hassles35.636.330.5<.01 Frustrations33.943.344.4<.01 Worry/concern48.968.846.6<.01 Burden31.050.532.7<.01 Management stress 36.147.837.2<.01

29. Correlation Health Status Measures with HbA1c Health status measuresHbA1c SF-36 PFI10.01 SF-36 Role physical.04 WHO-.03 EuroQual-.03 Diabetes Hassles.17*** Diabetes Frustration.18*** Diabetes Worry/Concern.25*** Diabetes Burden.27*** DM Management Stress.21*** ***p<.001

30. Coached Care for Diabetes Program: DAWN Minority Trial Results

31. Mean HbA1c Preliminary Results Study Period N Coached Care ControlMean Diff Baseline 2448.28.40.2 6 months 1598.18.30.1 12 months 1127.78.30.6* *p<.05

32. HbA1c >8% Preliminary Results Study Period N Coached Care ControlMean Diff Baseline 1259.4 0.0 6 months 649.08.9-0.1 12 months 387.99.41.6* **p<.01

33. Conclusions Coached Care may improve diabetes outcomes among poor and ethnic minorities Despite disparities in diabetes care at baseline, Coached Care improved HbA1c, diabetes health status across ethnic groups Community-based coaches of same culture can be trained; less expensive